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Abstract Background The Organ Procurement and Transplant Network (OPTN) Final Rule guides national organ transplantation policies, mandating equitable organ allocation and organ-specific priority stratification systems. Current allocation scores rely on mortality predictions. Methods We examined the alignment between the ethical priorities across organ prioritization systems and the statistical design of the risk models in question. We searched PubMed for literature on organ allocation history, policy, and ethics in the United States. Results We identified 127 relevant articles, covering kidney (19), liver (60), lung (24), and heart transplants (23), and transplant accessibility (1). Current risk scores emphasize model performance and overlook ethical concerns in variable selection. The inclusion of race, sex, and geographical limits as categorical variables lacks biological basis; therefore, blurring the line between evidence-based models and discrimination. Comprehensive ethical and equity evaluation of risk scores is lacking, with only limited discussion of the algorithmic fairness of the Model for End-Stage Liver Disease (MELD) and the Kidney Donor Risk Index (KDRI) in some literature. We uncovered the inconsistent ethical standards underlying organ allocation scores in the United States. Specifically, we highlighted the exception points in MELD, the inclusion of race in KDRI, the geographical limit in the Lung Allocation Score, and the inadequacy of risk stratification in the Heart Tier system, creating obstacles for medically underserved populations. Conclusions We encourage efforts to address statistical and ethical concerns in organ allocation models and urge standardization and transparency in policy development to ensure fairness, equitability, and evidence-based risk predictions.

On 24 January 2023, Eurotransplant has introduced the virtual crossmatch for kidney and pancreas allocation as a better alternative for the physical Complement Dependent Cytotoxicity (CDC) crossmatches at the donor centre, which were associated with a longer cold ischaemia time and false positive reactions. For the time being, the physical CDC crossmatch at the recipient centre will remain in place as the final histocompatibility check. While Eurotransplant is certainly not the first organ allocation organisation to introduce virtual crossmatching, several novel aspects have been introduced, such as calculation of the virtual panel reactive antibody (vPRA) on 11 loci at the second‐field level in addition to the serological broad and split level, electronic HLA typing data transmission using Histoimmunogenetics Markup Language (HML) file format, and the actual virtual crossmatch based on ambiguous, second‐field HLA typing of the donor on all 11 loci. This short communication will focus on these novel aspects of the virtual crossmatch in Eurotransplant. [ABSTRACT FROM AUTHOR]

To maximize utility and prevent premature liver transplantation (LT), a delayed LT strategy (DS) was adopted in France in 2015 in patients listed for any single HCC treated with resection or thermal ablation during the waiting phase. The DS involves postponing LT until recurrence. The purpose of this study was to evaluate the DS to make sure that it did not hamper pre- and post-LT outcomes. Patients listed for HCC in France between 2015 and 2018 were studied. After data extraction from the national LT database, 2,025 patients were identified and classified according to six groups: single tumor entering DS, single tumor not entering DS, multiple tumors, no curative treatment, untreatable HCC or T1 tumors. Kaplan-Meier estimates of the 18-month risk of dropout for death, too sick to be transplanted or tumor progression before LT, 5-year post-LT HCC recurrence and post-LT survival rates were compared. Median waiting-time in the DS group was 910 days. Pre-LT dropout probability was significantly lower in the DS group compared to other groups (13% vs. 19%, p = 0.0043) and significantly higher in the T1 group (25.4%, p = 0.05). Post-LT HCC recurrence rate in the multiple nodules group was significantly higher (19.6%, p = 0.019), while 5-year post-LT survival did not differ among groups and was 74% in the DS group (p = 0.22). The DELTA-HCC study shows that DS does not negatively impact either pre- nor post-LT patient outcomes, and has the potential to allow for redistribution of organs to patients in more urgent need of LT. It can reasonably be proposed and pursued. The unexpectedly high risk of dropout in T1 patients seems related to the MELD-based offering rules underserving this subgroup. To maximize utility and prevent premature liver transplantation (LT), a delayed LT strategy was adopted in France in 2015. It involves postponing LT until recurrence in patients listed for any single HCC curatively treated by surgical resection or thermal ablation. The DELTA-HCC study was conducted to evaluate this nationwide strategy. It shows in a European LT program that delayed strategy does not negatively impact pre- nor post-LT patient outcomes and is relevant to up to 20% of LT candidates; thus, it could potentially enable the redistribution of organs to patients in more urgent need of LT. Such a delayed strategy can reasonably be pursued and extended to other LT programs. Of note, an unexpectedly high risk of dropout in T1 patients, seemingly related to MELD-based offering rules which underserve these patients, calls for further scrutinization and revision of allocation rules in this subgroup. [Display omitted] • Patients with single curatively treated HCC account for 20% of LT candidates. • In these patients, LT can be safely delayed without hampering pre/post-LT outcomes. • This strategy has the potential to redirect spared organs to patients in urgent need. • The DELTA-HCC study supports extension of a delayed strategy to other LT programs. [ABSTRACT FROM AUTHOR]

Background: The 2014 Kidney Allocation System (KAS) revision aimed to enhance equity in organ allocation and improve patient outcomes. This study assesses the impacts of the KAS revision on renal transplantation demographics and outcomes in the United States. Methods: We conducted a retrospective study utilizing the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients (OPTN/SRTR) database from 1998 to 2022. We compared recipient and donor characteristics, and outcomes (graft failure and recipient survival) pre- and post-KAS revision. Results: Post-KAS, recipients were significantly older (53 vs 48, P <.001) with an increase in Medicaid beneficiaries (7.3% vs 5.5%, P <.001). Despite increased graft survival, HR =.91 (95% CI 0.80-.92, P <.001), overall recipient survival decreased, HR = 1.06 (95% CI 1.04-1.09, P <.001). KAS revision led to greater racial diversity among recipients and donors, enhancing equity in organ allocation. However, disparities persist in graft failure rates and recipient survival across racial groups. Discussion: The 2014 Kidney Allocation System revision has led to important changes in the renal transplantation landscape. While progress has been made towards increasing racial equity in organ allocation, further refinements are needed to address ongoing disparities. Recognizing the changing patient profiles and socio-economic factors will be crucial in shaping future policy modifications. [ABSTRACT FROM AUTHOR]

Working with U.S. policymakers to redesign national organ allocation The Organ Procurement & Transplantation Network (OPTN), which manages transplantation activities in the United States, recently partnered with the MIT Operations Research Center to design and implement novel organ allocation policies that are more equitable, efficient, and inclusive. National organ allocation policies need to strike a delicate balance between efficiency and fairness in multiple objectives, reconciling often disparate value judgments and priorities from many different stakeholders. In "Reshaping National Organ Allocation Policy," T. Papalexopoulos, J. Alcorn, and D. Bertsimas et al. introduced a novel optimization- and machine learning-based framework to aid policy design and navigate challenging fairness-efficiency tradeoffs. The authors collaborated with the OPTN to apply the framework to the design of a new national allocation policy for lungs, which was implemented in March 2023 and is anticipated to reduce waitlist mortality by approximately 20%. Based on this success, the authors are now working toward the redesign of the entire U.S. organ allocation system, including kidneys, pancreata, hearts, and livers. The Organ Procurement & Transplantation Network (OPTN) initiated in 2018 a major overhaul of all U.S. deceased-donor organ allocation policies, aiming to gradually migrate them to a so-called continuous distribution model, with the goal of creating an allocation system that is more efficient, more equitable, and more inclusive. Development of policies within this model, however, represents a major challenge because multiple efficiency and fairness objectives need to be delicately balanced. We introduce a novel analytical framework that leverages machine learning, simulation, and optimization to illuminate policy tradeoffs and enable dynamic exploration of the efficient frontier of policy options. In collaboration with the OPTN, we applied the framework to design a new national allocation policy for lungs. Since March 9, 2023, all deceased-donor lungs in the United States have been allocated according to this policy that we helped design, projected to reduce waitlist mortality by approximately 20% compared with current policy based on simulations. We discuss how we extended our collaboration with the OPTN to the redesign of kidney, pancreas, heart, and liver allocation and how our framework can be applied to other application domains, such as school choice or public housing allocation systems. Supplemental Material: The e-companion is available at https://doi.org/10.1287/opre.2022.0035. [ABSTRACT FROM AUTHOR]

Background: Kidney transplantation is the optimal treatment for end‐stage renal disease. However, highly sensitized patients (HSPs) have reduced access to transplantation, leading to increased morbidity and mortality on the waiting list. The Canadian Willingness to Cross (WTC) program proposes allowing transplantation across preformed donor specific antibodies (DSA) determined to be at a low risk of rejection under the adaptive design framework. This study collected patients' perspectives on the development of this program. Methods: Forty‐one individual interviews were conducted with kidney transplant candidates from three Canadian transplant centers in 2022. The interviews were digitally recorded and transcribed for subsequent analyses. Results: Despite limited familiarity with the adaptive design, participants demonstrated trust in the researchers. They perceived the WTC program as a pathway for HSPs to access transplantation while mitigating transplant‐related risks. HSPs saw the WTC program as a source of hope and an opportunity to leave dialysis, despite acknowledging inherent uncertainties. Some non‐HSPs expressed concerns about fairness, anticipating increased waiting times and potential compromise in kidney graft longevity due to higher rejection risks. Participants recommended essential strategies for implementing the WTC program, including organizing informational meetings and highlighting the necessity for psychosocial support. Conclusion: The WTC program emerges as a promising strategy to enhance HSPs' access to kidney transplantation. While HSPs perceived this program as a source of hope, non‐HSPs voiced concerns about distributive justice issues. These results will help develop a WTC program that is ethically sound for transplant candidates. [ABSTRACT FROM AUTHOR]

To designed a new model using pre-transplant data to predict post-transplant mortality for Chinese population and compared its performance to that of existing models. In this multicenter study, 544 recipients of liver transplants for non-tumor indications were enrolled in the training group and 276 patients in the validation group. The new Simplified Mortality Prediction Scores (SMOPS) model was compared to the MELD and four existing models using the C-statistic. SMOPS model used 6 independent pre-transplantation risk factors screened from the training group (chronic liver failure/organ failure scores, fever > 37.6 ℃, ABO blood-type compatibility, arterial lactate level, leukocyte count and re-transplantation). The SMOPS accurately predicted patients' 30-day, 90-day and 365-day mortality following liver transplantation, and its' scores were more accurate than those of the other models. The SMOPS generated four levels of risk: low risk (<10 points), moderate risk (11–20 points), high risk (21–25 points) and futile risk (≥26 points). The survival within all risk levels was not different between MELD=40 and MELD<40. The survival within moderate-, high- or extreme-risk ALF was not different between ALF and non-ALF. The SMOPS model uses pre-transplant risk factors to stratify post-transplant survival and is superior to current models for Chinese population, and has the potential to contribute to improvements in organ-allocation policies. [ABSTRACT FROM AUTHOR]

Background: Over the last decade there has been a surge in overdose deaths due to the opioid crisis. We sought to characterize the temporal change in overdose donor (OD) use in liver transplantation (LT), as well as associated post‐LT outcomes, relative to the COVID‐19 era. Methods: LT candidates and donors listed between January 2016 and September 2022 were identified from the Scientific Registry of Transplant Recipients database. Trends in LT donors and changes related to OD were assessed pre‐ versus post‐COVID‐19 (February 2020). Results: Between 2016 and 2022, most counties in the United States experienced an increase in overdose‐related deaths (n = 1284, 92.3%) with many counties (n = 458, 32.9%) having more than a doubling in drug overdose deaths. Concurrently, there was an 11.2% increase in overall donors, including a 41.7% increase in the number of donors who died from drug overdose. In pre‐COVID‐19 overdose was the 4th top mechanism of donor death, while in the post‐COVID‐19 era, overdose was the 2nd most common cause of donor death. OD was younger (OD: 35 yrs, IQR 29–43 vs. non‐OD: 43 yrs, IQR 31–56), had lower body mass index (≥35 kg/cm2, OD: 31.2% vs. non‐OD: 33.5%), and was more likely to be HCV+ (OD: 28.9% vs. non‐OD: 5.4%) with lower total bilirubin (≥1.1 mg/dL, OD: 12.9% vs. non‐OD: 20.1%) (all p <.001). Receipt of an OD was not associated with worse graft survival (HR.94, 95% CI.88–1.01, p =.09). Conclusions: Opioid deaths markedly increased following the COVID‐19 pandemic, substantially altering the LT donor pool in the United States. [ABSTRACT FROM AUTHOR]

Background Infectious diseases (IDs) are highly relevant after solid organ transplantation in terms of morbidity and mortality, being among the most common causes of death. Patients undergoing kidney retransplantation (re-K-Tx) have been already receiving immunosuppressive therapy over a prolonged period, potentially facilitating subsequent infections. Comparing ID events after re-K-Tx and first kidney transplantation (f-K-Tx) can delineate patterns and risks of ID events associated with prolonged immunosuppression. Methods We included adult patients with records on f-K-Tx and re-K-Tx in the Swiss Transplant Cohort Study. We analyzed ID events after f-K-Tx and re-K-Tx within the same patients and compared infection rates, causative pathogens, and infection sites. Recurrent time-to-event analyses were performed for comparison of infection rates. Results A total of 59 patients with a median age of 47 years (range, 18–73) were included. Overall, 312 ID events in 52 patients occurred. In multivariable recurrent event modeling, the rate of ID events was significantly lower after re-K-Tx (hazard ratio, 0.70; P =.02). More bacterial (68.9% vs 60.4%) and fungal (4.0% vs 1.1%) infections were observed after f-K-Tx but fewer viral infections (27.0% vs 38.5%) as compared with re-K-Tx (P =.11). After f-K-Tx, urinary and gastrointestinal tract infections were more frequent; after re-K-Tx, respiratory tract and surgical site infections were more frequent (P <.001). Conclusions ID events were less frequent after re-K-Tx. Affected sites differed significantly after f-K-Tx vs re-K-Tx. [ABSTRACT FROM AUTHOR]

Background: Predicting post-transplant (PT) survival in lung allocation remains an elusive goal. We analyzed the impact of donor factors on PT survival and how these relationships vary among transplant recipients. Methods: We studied primary bilateral lung transplant recipients (n = 7,609) from the US Scientific Registry of Transplant Recipients (19 February 2015-1 February 2020). Main and interaction effects were evaluated and adjusted across candidate age, sex, and diagnosis. Models predicting PT survival were compared to the PT Composite Allocation Score model (PT-CAS): (1) Cox regression donor multivariable model (COX), (2) COX + PT-CAS, (3) random forest model (RF), and (4) RF + PT-CAS. Model discrimination and calibration measures were compared. Results: Interactions between donor and recipient factors emerged by age: lower survival for donation after circulatory death organs for recipients aged 55 to 69 years, donor smoking for recipients aged 30 to 54 and 70+, Hispanic donor for recipients

Some patients with coronavirus disease 19 (COVID) develop serious, irreversible lung disease, including acute respiratory distress syndrome or pulmonary fibrosis. For select candidates, lung transplant is the only option to improve quality and length of life. Because of the severity of end‐stage COVID‐related lung disease, these candidates receive high allocation priority in the United States, including higher priority than many patients without COVID‐related lung disease. This study assessed whether transplant centers with a large volume of COVID‐related lung transplants experienced an increase in waitlist mortality for non‐COVID transplant candidates. Nineteen centers were included as high‐volume programs, defined as being in the top third of centers who transplanted COVID patients. Of the 2867 non‐COVID patients waitlisted at these centers, there was no significant difference in waitlist mortalities of non‐COVID transplant candidates between the pre‐COVID transplant era (January 2018–February 2020) and during the period of high COVID transplant volume (March 2020–October 2022) (subhazard ratio:.92 [95% CI =.81–1.05], p =.22). Among high volume centers, the decision to transplant and to prioritize patients with COVID‐related lung disease did not significantly impact the waitlist mortality of other candidates. [ABSTRACT FROM AUTHOR]

Background: Despite South Africa's rich heritage as pioneers in organ transplantation, access to organs remains a major issue in the Gauteng province. This is secondary to an array of socioeconomic and political factors that have implications for organ distribution. Our aim was to assess the contribution of the public sector to solid organ transplantation in Gauteng province and compare the distribution of solid organs between the recipient groups. Methods: This was a retrospective registry review of consented brain‐dead donors from the public sector within Gauteng from January 1, 2016, to June 30, 2021, coordinated at Charlotte Maxeke Johannesburg Academic Hospital, a tertiary academic hospital. Results: Records of 49 deceased donors were analyzed. Mean donor age was 31.5 years with the age group 30–39 years constituting the majority of deceased donors at 15/49 (30.6%); 10/49 (16%) were from pediatric donors. There was a significant discrepancy in allocation between public and private sector in cardiac (p =.012) and liver allocation (p <.001) and adult and pediatric recipients for all solid organs (p <.001). There was a significant increase in the rate and number (p =.0026) of pediatric kidney transplants occurring after March 1, 2020, when there was a transition to a public sector‐mandated kidney transplant waitlist. Conclusion: Current disparities in organ distribution have a significant impact on public sector recipients, especially pediatric patients. This is likely secondary to paucity of legislation and resource limitations which would benefit from improved governmental policies and explicit pediatric prioritization policies in transplant units. [ABSTRACT FROM AUTHOR]

Every patient with kidney failure requiring dialysis in Germany has the right to at least be evaluated for a transplantation. When an affected person can be considered for a transplantation, it must be clarified which allocation program is the right one for the person and whether a living organ donor can be considered. It should also be individually discussed with patients which type of donor organ should be accepted. Following a transplantation an individualized immunosuppression is relevant not only for the long-term survival of the transplant but also for the adherence of the patient. [ABSTRACT FROM AUTHOR]

The practice of deceased-donor solid-organ transplantation is unique among clinical therapies because it substantially benefits recipients, The allocation process is a complex System-of-Systems (SoS) with multiple stakeholders, components, rules, and policies. While we model and simulate such SoS, they are challenging to verify and validate thoroughly due to a large number of use cases and the sensitivity to initial conditions. Furthermore, subject matter experts within communities of practice do not trust such models because they are difficult to explain. This paper proposes a trust-centric approach to validation focusing on experimentally exploring the simulation's behavior space and demonstrating its utility to a community of experts. We describe a three-step validation process to show how modelling and simulation professionals can foster trust in simulations of a complex SoS. We apply the framework to verify and validate a simulation model of the Kidney–Pancreas (KP) allocation process within the United States. [ABSTRACT FROM AUTHOR]

Recent studies showed that ABO‐adjusted calculated panel reactive antibody (ABO‐cPRA) may better reflect the histocompatibility level in a multi‐ethnic population, but such data in Asians is not available. We developed an ABO‐adjusted cPRA metric on a cohort of waitlist kidney transplant patients (n = 647, 99% Chinese) in Hong Kong, based on HLA alleles and ABO frequencies of local donors. The concordance between the web‐based ABO‐cPRA calculator and the impact on kidney allocation were evaluated. The blood group distribution for A, B, O and AB among waitlist kidney candidates were 26.2%, 27.5%, 40.1%, and 6.1%, and their chances of encountering incompatible blood group donors were 32.6%, 32.4%, 57.6%, and 0%, respectively. There is poor agreement between web‐based ABO‐cPRA calculator and our locally developed metrics. Over 90% of patients showed an increase in cPRA after ABO adjustment, most notably in those with cPRA between 70% and 79%. Blood group O patients had a much greater increase in cPRA scores after adjustment while patients of blood group A and B had similar increment. 10.6% of non‐AB blood group waitlist patients had ABO‐cPRA elevated to ≥80%. A local ABO‐adjusted cPRA metric is required for Asian populations and may improve equity in kidney distribution for patients with disadvantageous blood groups. The result from the current study potentially helps other countries/localities in establishing their own unified ABO‐cPRA metrics and predict the impact on kidney allocation. [ABSTRACT FROM AUTHOR]

On 6/18/2020, the Organ Procurement and Transplantation Network (OPTN) implemented new policy replacing OPTN region with a 500 nautical mile (NM) circle around the donor hospital for the purpose of vascularized composite allograft (VCA) allocation. We used OPTN data to assess deceased donor VCA transplants in the 3 years pre- (6/19/2017–6/17/2020) vs. post-implementation (6/18/2020–6/17/2023). A total of 19 deceased donor VCA transplants were performed pre-policy (10 uterus, 3 bilateral upper limb, 1 unilateral upper limb, 3 face, 1 abdominal wall and 1 penis), and 11 post-policy (4 uterus, 1 bilateral upper limb, 2 face, 1 trachea, 2 abdominal wall, and 1 bilateral upper limb and face). Median distance from donor hospital to transplant hospital increased from 70 NM (range: 0–524 NM) pre-policy to 119 NM (range: 0–464 NM) post-policy. The majority of transplants in both policy eras were within 500 NM of the donor hospital [89.5% (N = 17/19) vs. 100% (N = 11/11)] and most remained within the same OPTN region as the donor hospital [68.4% (N = 13/19) vs. 90.9% (N = 10/11)]. Although it is difficult to draw strong conclusions about the policy's impact due to the low transplant volume and timing of implementation relative to the COVID-19 pandemic, data in the 3 years post-implementation suggest that 500 NM circles were a reasonable replacement for OPTN region in VCA allocation. The OPTN will continue to review data to monitor the policy's impact and inform future changes to VCA allocation, such as the transition to continuous distribution, a points-based framework expected to replace the current framework.

BackgroundMost patients are listed for liver transplant (LT) following extensive workup as outpatients ("conventional evaluation"). Some patients undergo urgent evaluation as inpatients after being transferred to a transplant center ("expedited evaluation"). We hypothesized that expedited patients would have inferior survival due to disease severity at the time of transplant and shorter workup time.MethodsPatients who underwent evaluation for LT at our institution between 2012 and 2016 were retrospectively reviewed. The expedited and conventional cohorts were defined as above. Living donor LT recipients, combined liver-kidney recipients, acute liver failure patients, and re-transplant patients were excluded. We compared patient characteristics and overall survival between patients who received a transplant following expedited evaluation and those who did not, and between LT recipients based on expedited or conventional evaluation.ResultsFive-hundred and nine patients were included (110 expedited, 399 conventional). There was no difference in graft or patient survival at 1 year for expedited versus conventional LT recipients. In multivariable analysis of overall survival, only Donor Risk Index (HR 1.97, CI 1.04-3.73, P = .037, per unit increase) was associated with increased risk of death.ConclusionsPatients who underwent expedited evaluation for LT had significant demographic and clinical differences from patients who underwent conventional evaluation, but comparable post-transplant survival.

Abstract Background Allocation of scarce organs for transplantation is ethically challenging. Artificial intelligence (AI) has been proposed to assist in liver allocation, however the ethics of this remains unexplored and the view of the public unknown. The aim of this paper was to assess public attitudes on whether AI should be used in liver allocation and how it should be implemented. Methods We first introduce some potential ethical issues concerning AI in liver allocation, before analysing a pilot survey including online responses from 172 UK laypeople, recruited through Prolific Academic. Findings Most participants found AI in liver allocation acceptable (69.2%) and would not be less likely to donate their organs if AI was used in allocation (72.7%). Respondents thought AI was more likely to be consistent and less biased compared to humans, although were concerned about the “dehumanisation of healthcare” and whether AI could consider important nuances in allocation decisions. Participants valued accuracy, impartiality, and consistency in a decision-maker, more than interpretability and empathy. Respondents were split on whether AI should be trained on previous decisions or programmed with specific objectives. Whether allocation decisions were made by transplant committee or AI, participants valued consideration of urgency, survival likelihood, life years gained, age, future medication compliance, quality of life, future alcohol use and past alcohol use. On the other hand, the majority thought the following factors were not relevant to prioritisation: past crime, future crime, future societal contribution, social disadvantage, and gender. Conclusions There are good reasons to use AI in liver allocation, and our sample of participants appeared to support its use. If confirmed, this support would give democratic legitimacy to the use of AI in this context and reduce the risk that donation rates could be affected negatively. Our findings on specific ethical concerns also identify potential expectations and reservations laypeople have regarding AI in this area, which can inform how AI in liver allocation could be best implemented.

In this transformative era of organ transplantation, integrating Smart Match and artificial intelligence (AI) emerges as a pivotal advancement, revolutionizing organ allocation processes. Smart Match employs AI algorithms, enhancing organ matching precision and optimizing transplantation outcomes. Leveraging machine learning addresses complexities in donor-recipient pairing, immunosuppression management, and post-operative care, promising to minimize waitlist mortality and improve patient wellbeing. The multifaceted potential of Smart Match lies in its ability to not only streamline current practices but also pave the way for future innovations in solid organ transplantation. As technology continues to evolve, the collaboration between Smart Match and AI exemplifies a beacon of progress, promising increased efficiency, equitable organ distribution, and improved patient care. This article delves into the paradigm shift facilitated by Smart Match and AI, emphasizing their transformative impact on the landscape of organ allocation and patient outcomes.

Background: Allocation of scarce organs for transplantation is ethically challenging. Artificial intelligence (AI) has been proposed to assist in liver allocation, however the ethics of this remains unexplored and the view of the public unknown. The aim of this paper was to assess public attitudes on whether AI should be used in liver allocation and how it should be implemented. Methods: We first introduce some potential ethical issues concerning AI in liver allocation, before analysing a pilot survey including online responses from 172 UK laypeople, recruited through Prolific Academic. Findings: Most participants found AI in liver allocation acceptable (69.2%) and would not be less likely to donate their organs if AI was used in allocation (72.7%). Respondents thought AI was more likely to be consistent and less biased compared to humans, although were concerned about the "dehumanisation of healthcare" and whether AI could consider important nuances in allocation decisions. Participants valued accuracy, impartiality, and consistency in a decision-maker, more than interpretability and empathy. Respondents were split on whether AI should be trained on previous decisions or programmed with specific objectives. Whether allocation decisions were made by transplant committee or AI, participants valued consideration of urgency, survival likelihood, life years gained, age, future medication compliance, quality of life, future alcohol use and past alcohol use. On the other hand, the majority thought the following factors were not relevant to prioritisation: past crime, future crime, future societal contribution, social disadvantage, and gender. Conclusions: There are good reasons to use AI in liver allocation, and our sample of participants appeared to support its use. If confirmed, this support would give democratic legitimacy to the use of AI in this context and reduce the risk that donation rates could be affected negatively. Our findings on specific ethical concerns also identify potential expectations and reservations laypeople have regarding AI in this area, which can inform how AI in liver allocation could be best implemented. [ABSTRACT FROM AUTHOR]

The FOEDUS-EOEO platform was relaunched in 2015 to allocate deceased donor organs across European borders when there are no suitable recipients in the donor's country. We analyzed organ offers from 01.06.2015-31.12.2021 and present the number of offers and transplants, and utilization as percentage of transplanted organs. 1,483 organs were offered, 287 were transplanted (19.4% utilization). Yearly number of offers and transplants increased from 2017 to 2021, while utilization stabilized after 2018. Utilization was highest for organs offered by Slovakia (47.2%), followed for organs offered by Lithuania, France, Greece, and Czechia (19.3%-22.9%). The most frequently offered organ was the heart (n = 405; 27.3%), followed by the lungs (n = 369; 24.9%) and the liver (n = 345; 23.3%). Utilization differed significantly by organ type (highest for liver, 35.7%; followed by heart, 18.8%; and kidney, 18.3%) and by donor age (highest for 1 to 5 year-old donors (25.0%)). FOEDUS-EOEO allowed for many European patients receiving a long-awaited transplant, especially for very young pediatric patients waiting for a liver, a heart, or a kidney. The increasing number of participating countries has increased both the number of offered organs and, to a lesser extent, the number of transplanted organs. [ABSTRACT FROM AUTHOR]

Introduction: Expedited out‐of‐sequence deceased donor kidney allocation is a strategy to avoid discards after early placement attempts have been unsuccessful. Our study aimed to assess outcomes and characteristics of these transplanted kidneys. Methods: KDPI matching was performed between expedited allocation (EA) and standard allocation (SA) deceased donor kidney transplants performed at our center. Results: Between 2018 and 2021, there were 225 EA offers, and 189 (84%) were transplanted. EA recipients were older (p =.007) and had shorter dialysis vintage (p <.0001). EA kidneys were likely to be nationally allocated (p <.001), have AKI (p <.0001) and longer CIT (p <.0001). There were no differences in EA and SA time‐zero kidney biopsies (ci, p =.07; ct, p =.89; cv, p =.95; ah, p =.79). EA kidneys had more DGF (p =.0006), but there were no differences in DGF duration (p =.83), hospital length of stay (p =.43), 1‐ and 2‐year eGFR (p =.16, p =.99), patient (p =.34), or death‐censored graft (p =.66) survival. Conclusion: During this study period, our center transplanted 189 kidneys through EA following local‐regional declines. These kidneys often came from AKI donors and had more DGF but had similar outcomes to KDPI‐matched SA kidneys. Although it has been suggested that EA has the potential to worsen transplant disparities, transplant center level decisions on organ acceptance contribute to these variations. [ABSTRACT FROM AUTHOR]

Rationale: U.S. lung transplant mortality risk models do not account for patients' disease progression as time accrues between mandated clinical parameter updates. Objectives: To investigate the effects of accrued waitlist (WL) time on mortality in lung transplant candidates and recipients beyond those expressed by worsening clinical status and to present a new framework for conceptualizing mortality risk in end-stage lung disease. Methods: Using Scientific Registry of Transplant Recipients data (2015-2020, N= 12,616), we modeled transitions among multiple clinical states over time:WL, posttransplant, and death. Using causespecific and ordinary Cox regression to estimate trajectories of composite 1-year mortality risk as a function of time from waitlisting to transplantation, we quantified the predictive accuracy of these estimates.We compared multistate model-derived candidate rankings against composite allocation score (CAS) rankings. Measurements and Main Results: There were 11.5% of candidates whose predicted 1-year mortality risk increased by >10% by day 30 on the WL. The multistate model ascribed lower numerical rankings (i.e., higher priority) than CAS for those who died while on the WL (multistate mean; median [interquartile range] ranking at death, 227; 154 [57-334]; CAS median [interquartile range] ranking at death, 329; 162 [11-668]). Patients with interstitial lung disease were more likely to have increasing risk trajectories as a function of time accrued on the WL compared with other lung diagnoses. Conclusions: Incorporating the effects of time accrued on the WL for lung transplant candidates and recipients in donor lung allocation systems may improve the survival of patients with end-stage lung diseases on the individual and population levels. [ABSTRACT FROM AUTHOR]

Purpose: Liver transplant (LT) is the only definitive treatment for end-stage liver disease (ESLD). This review aims to explore current global LT practices, with an emphasis on challenges and disparities that limit access to LT in different regions of the world. Methods: A detailed analysis was performed of present-day liver transplant practices throughout the world, including the etiology of liver disease, patient access to transplantation, surgical costs, and ongoing ethical concerns. Results: Annually, only 10% of the patients needing a liver transplant receive an organ. Currently, the USA performs the highest volume of liver transplants worldwide, followed by China and Brazil. In both North America and Europe, nonalcoholic fatty liver disease is becoming the most common indication for LT, compared to hepatitis B and C in most Asian, South American, and African countries. While deceased donor liver transplant remains the most performed type of LT, living donor liver transplant is becoming increasingly popular in some parts of the world where it is often the only option due to a lack of well-developed infrastructure for deceased organ donation. Ethical concerns in liver transplantation fundamentally revolve around the definition of a deceased donor and the exploitation of living donor liver donation systems. Conclusion: Globally, liver transplant practices and outcomes are varied, with differences driven by healthcare policies, inequities in healthcare access, and ethical concerns. [ABSTRACT FROM AUTHOR]

Background: To address long waitlist times and increase pancreas transplantation, our center has implemented a protocol for long‐distance importation of pancreata. Methods: We conducted a retrospective review of pancreas transplantation at our institution from January 1, 2014, the start of our importation program, through September 30, 2021. Outcomes were compared between locally procured grafts and imported grafts, defined as grafts procured greater than 250 nautical miles (NM) from our center. Results: Eighty‐one patients underwent pancreas transplantation during the study time period; 19 (23.5%) received imported grafts. There were no significant differences in recipient demographics or type of transplant received. Mean distance of import was 644.2 ± 234.0 NM. Imported grafts were more likely to be from pediatric donors <18 years old (p =.02) and a significantly higher proportion of imported grafts came from donors weighing <30 kg (26.3 vs. 3.2%, p =.007). Cold ischemic time was longer for imported grafts than for local grafts (13.4 ± 2.3 h vs. 9.8 ± 2.2 h, p <.01). There was no significant difference in deaths or graft losses within 90 days or at 1 year between groups. Conclusion: Centers should consider expanding criteria for acceptance of imported pancreata to increase the number of transplants and combat organ nonutilization. [ABSTRACT FROM AUTHOR]

Intestinal donor criteria are classically kept strict, thereby limiting donor supply. Indications for intestinal transplantation (ITx) are rare, but improved outcome and new emerging indications lead to increased demand and relaxing donor criteria should be considered. We sought to compare the donor criteria of intestines transplanted at our center with predefined (per protocol) criteria, and to determine how relaxing donor criteria could impact the potential donor pool. Donor criteria used in 22 consecutive ITx at our center between 2000 and 2020 were compared with predefined criteria. Next, multiorgan donors effectively offered by our Donor Network to Eurotransplant between 2014 and 2020 were retrospectively screened, according to predefined and effectively used intestinal donation criteria. Finally, utilization rate of offered intestines was calculated. In our ITx series, the effectively used donor criteria were less strict than those initially predefined. With these relaxed criteria, a favorable 5-year graft/patient survival of 75% and 95%, respectively was reached. Applying these relaxed criteria would lead to a 127% increase in intestinal offers. Paradoxically, 70% of offered intestines were not used. In conclusion, a significant increase in intestinal donation could be obtained by relaxing donor criteria, while still achieving excellent outcome. Offered intestines are underutilized. [ABSTRACT FROM AUTHOR]

In 2019, the United Network for Sharing (UNOS), which has been operating the Organ Procurement and Transplantation Network (OPTN) in the United States since 1984, was seeking to design a new national lung transplant allocation policy. The goal was to develop a point system that would prioritize candidates on the waiting list in a way that would yield more efficient and equitable outcomes. Our joint Massachusetts Institute of Technology (MIT)/UNOS team joined forces with the OPTN Lung Transplantation Committee in these policy design efforts. We discuss how our team applied a novel analytical framework, which was developed at MIT and utilizes optimization, regression, and simulation techniques, to illuminate salient trade-offs among outcomes and guide the choice of how to weigh different point attributes in the allocation formula. The committee selected for the allocation formula weights that were highlighted in the team's analysis. The team's proposal was implemented as the national lung allocation policy on March 9, 2023 across the United States. [ABSTRACT FROM AUTHOR]

HLA antibodies are typically produced after exposure to transplanted tissue, pregnancy, and blood products. Sensitization delays access to transplantation and preclude utilization of donor organs. Infections and vaccinations have also been reported to result in HLA antibody formation. It is not known if patients develop HLA antibodies after infection with SARS-CoV-2. Here we analyzed a series of eighteen patients waiting for kidney transplantation who had symptomatic COVID-19 disease and recovered. None of the patients in this initial series developed de novo HLA antibodies. Notably, there was no increase in preexisting HLA antibodies in four highly sensitized patients with a CPRA > 80%. These preliminary data suggest that there may not be a need to repeat HLA antibody testing or perform a physical crossmatch on admission serum before kidney transplant for COVID-19 recovered patients. Data from a large number of patients with different demographics needed.

Living donor liver transplantation (LDLT) enjoys widespread use in Asia, but remains limited to a handful of centers in North America and comprises only 5% of liver transplants performed in the United States. In contrast, living donor kidney transplantation is used frequently in the United States, and has evolved to commonly include paired exchanges, particularly for ABO-incompatible pairs. Liver paired exchange (LPE) has been utilized in Asia, and was recently reported in Canada; here we report the first LPE performed in the United States, and the first LPE to be performed on consecutive days. The LPE performed at our institution was initiated by a nondirected donor who enabled the exchange for an ABO-incompatible pair, and the final recipient was selected from our deceased donor waitlist. The exchange was performed over the course of 2 consecutive days, and relied on the use and compliance of a bridge donor. Here, we show that LPE is feasible at centers with significant LDLT experience and affords an opportunity to expand LDLT in cases of ABO incompatibility or when nondirected donors arise. To our knowledge, this represents the first exchange of its kind in the United States.

The FOEDUS-EOEO platform was relaunched in 2015 to allocate deceased donor organs across European borders when there are no suitable recipients in the donor’s country. We analyzed organ offers from 01.06.2015–31.12.2021 and present the number of offers and transplants, and utilization as percentage of transplanted organs. 1,483 organs were offered, 287 were transplanted (19.4% utilization). Yearly number of offers and transplants increased from 2017 to 2021, while utilization stabilized after 2018. Utilization was highest for organs offered by Slovakia (47.2%), followed for organs offered by Lithuania, France, Greece, and Czechia (19.3%–22.9%). The most frequently offered organ was the heart (n = 405; 27.3%), followed by the lungs (n = 369; 24.9%) and the liver (n = 345; 23.3%). Utilization differed significantly by organ type (highest for liver, 35.7%; followed by heart, 18.8%; and kidney, 18.3%) and by donor age (highest for 1 to 5 year-old donors (25.0%)). FOEDUS-EOEO allowed for many European patients receiving a long-awaited transplant, especially for very young pediatric patients waiting for a liver, a heart, or a kidney. The increasing number of participating countries has increased both the number of offered organs and, to a lesser extent, the number of transplanted organs.

Should priority in the allocation of organs be given to those who have previously donated or declared their willingness to do so? This article examines the Israeli priority rule in light of two prominent critiques of priority rules, pertaining to failure to reciprocate and unfairness. The scope and content of these critiques are interpreted from the perspective of equality of opportunity. Because the Israeli priority rule may be reasonably criticized for unfairness and failing to reward certain behaviors, the article develops an adjusted priority rule, which removes and adjust the elements in the Israeli priority rule deemed problematic. However, such a priority rule is complex to the extent that it may fail to increase donation rates and furthermore introduce new concerns of fairness, as the better off may be better able to navigate the complex adjusted priority rule. [ABSTRACT FROM AUTHOR]

Background: Appropriate patient selection for simultaneous heart‐kidney transplantation (sHK) in patients with moderate renal dysfunction remains challenging. Methods: From the United Network for Organ Sharing database (2003–2020), we identified 5678 adults with an estimated pre‐transplant glomerular filtration rate (eGFR) between 30 and 45 mL/min/1.73 m2 and no pre‐transplant dialysis. Patients undergoing sHK (n = 293) were compared with those undergoing heart transplantation alone (n = 5385) using 1:3 propensity score matching. Results: The sHK utilization rate increased from 1.8% in 2003 to 12.2% in 2020 (p <.001). After matching, 1 and 5‐year survival was 87.7% (95% confidence interval [CI] 83.3–91.0) and 80.0% (95% CI 74.2–84.6) after sHK, and 87.3% (95% CI 85.2–89.1) and 71.8% (95% CI 68.4–74.9) after heart transplant alone (p =.04). In the subgroup analysis, sHK was associated with a 5‐year survival benefit only in patients with 30 < eGFR ≤ 35 mL/min/1.73 m2 (p =.05) but not in those with 35 < eGFR < 45 mL/min/1.73 m2 (p =.45). Patients who underwent heart transplants alone also had a higher incidence of becoming chronic dialysis‐dependent after transplant within 5‐year follow‐up (10.2%, 95% CI 8.0–12.6 vs. 3.8%, 95% CI 1.7–7.1, p =.004). The 5‐year incidence of subsequent kidney waitlisting and transplants after heart transplants alone was 5.6% and 1.9%, respectively. Conclusion: Among propensity‐matched patients without pre‐transplant dialysis, compared to heart transplants alone, sHK had improved 5‐year survival in those with 30 < eGFR ≤ 35 but not in those with 35 < eGFR < 45 mL/min/1.73 m2. One‐year survival was similar irrespective of eGFR. Receiving a kidney after a heart transplant alone is rare under the current allocation system. [ABSTRACT FROM AUTHOR]

Due to demographic ageing and medical progress, the number and proportion of older organ donors and recipients is increasing. At the same time, the medical and ethical significance of ageing and old age for organ transplantation needs clarification. Advanced age is associated with the frailty syndrome that has a negative impact on the success of organ transplantation. However, there is emerging evidence that frailty can be modified by suitable prehabilitation measures. Against this backdrop, we argue that decision making about access to the transplant waiting list and the allocation of donor organs should integrate geriatric expertise in order to assess and manage frailty and impairments in functional capacity. Prehabilitation should be implemented as a new strategy for preoperative conditioning of older risk patients' functional capacity. From an ethical point of view, advanced chronological age per se should not preclude the indication for organ transplantation and the allocation of donor organs. [ABSTRACT FROM AUTHOR]

En raison du rôle néfaste des DSA (Donor specific antibody) anti-HLA-A/B/DR/DQ préformés en transplantation rénale, les systèmes d'allocation d'organes prennent en compte ces anticorps dans la décision de greffe. Cependant, de plus en plus d'études soulèvent le rôle des DSA anti-Cw et anti-DP préformés. En effet, à travers les données de la littérature, il apparaît que la présence de DSA anti-Cw et anti-DP impacte de manière préjudiciable la survie du greffon. Ces DSA sont incriminés dans la survenue de rejets de greffe, en corrélation avec les seuils de MFI (Mean fluorescence intensity) et leur potentiel pathologique. Néanmoins, aucun consensus n'est encore établi. Sont présentés ici deux cas de patients candidats à une transplantation rénale, chez qui la présence des DSA anti-Cw et anti-DP a entravé l'accès à la greffe. Cette stratégie, prenant en compte ces DSA dans la décision de greffe rénale, impose la réalisation du typage HLA-Cw et HLA-DP du donneur dès que le receveur potentiel présente une immunisation anti-Cw et/ou anti-DP. Due to the harmful impact of preformed anti-HLA-A/B/DR/DQ DSA (Donor Specific Antibody) on kidney transplantation, organ allocation systems take these antibodies into account in the transplant decision. Nevertheless, more and more studies point to the deleterious role of preformed anti-Cw and anti-DP antibodies as well. Indeed, it appears from the literature that the presence of anti-Cw and antiDP DSA adversely affects the survival of the graft. These DSA are incriminated in the occurrence of graft rejection, with a correlation of their MFI (Mean Fluorescence Intensity) thresholds with their pathological potential. However, no consensus has yet been established. We present two cases of patients candidates for kidney transplantation, for whom the presence of anti-Cw and anti-DP DSA hampered access to the transplant. This strategy, which takes these DSAs into account in the renal transplant decision, requires carrying out the HLA-Cw and HLA-DP typings of the donor as soon as the potential recipient presents an anti-Cw and/or anti-DP immunization. [ABSTRACT FROM AUTHOR]

There is a long-standing debate concerning the eligibility of patients suffering from alcohol-related end-stage liver disease (ARESLD) for deceased donor liver transplantation. The question of retrospective and/or prospective responsibility has been at the center of the ethical discussion. Several authors argue that these patients should at least be regarded as partly responsible for their ARESLD. At the same time, the arguments for retrospective and/or prospective responsibility have been strongly criticized, such that no consensus has been reached. A third option was proposed as a form of compromise, namely that responsibility should only be used as a tiebreaker in liver allocation. The present study provides an ethical investigation of this third option. First, we will provide an overview of the main arguments that have been offered for and against the use of responsibility as an allocation criterion. Second, we will explore the concept of responsibility as a tiebreaker in detail and discuss several types of situations, in which responsibility could be used as a tiebreaker, as well as the main ethical challenges associated with them. As we will show, an ethical justified use of responsibility as a tiebreaker is limited to a very restricted number of cases and is associated with a number of ethical concerns. For this reason, waiting time should be preferred as a tiebreaker in liver allocation, even though the criterion of waiting time, too, raises a number of equity-related concerns. [ABSTRACT FROM AUTHOR]

Split liver transplantation (SLT) is 1 strategy for maximizing the number of deceased donor liver transplants. Recent reports suggest that utilization of SLT in the United States remains low. We examined deceased donor offers that were ultimately split between 2010 and 2014. SLTs were categorized as "primary" and "secondary" transplants. We analyzed allocation patterns and used logistic regression to evaluate factors associated with secondary split discard. Four hundred eighteen livers were split: 54% from adult, 46% from pediatric donors. Of the 227 adult donor livers split, 61% met United Network for Organ Sharing "optimal" split criteria. A total of 770 recipients (418 primary and 352 secondary) were transplanted, indicating 16% discard. Ninety-two percent of the 418 primary recipients were children, and 47% were accepted on the first offer. Eighty-seven percent of the 352 secondary recipients were adults, and 7% were accepted on the first offer. Of the 352 pairs, 99% were transplanted in the same region, 36% at the same center. In logistic regression, shorter donor height was associated with secondary discard (odds ratio 0.97 per cm, 95% CI 0.94-1.00, P = .02). SLT volume by center was not predictive of secondary discard. Current policy proposals that incentivize SLT in the United States could increase the number of transplants to children and adults.

Heart failure (HF) is a leading cause of morbidity and mortality in the United States. While medical management and mechanical circulatory support have undergone significant advancement in recent years, orthotopic heart transplantation (OHT) remains the most definitive therapy for refractory HF. OHT has seen steady improvement in patient survival and quality of life (QoL) since its inception, with one-year mortality now under 8%. However, a significant number of HF patients are unable to receive OHT due to scarcity of donor hearts. The United Network for Organ Sharing has recently revised its organ allocation criteria in an effort to provide more equitable access to OHT. Despite these changes, there are many potential donor hearts that are inevitably rejected. Arbitrary regulations from the centers for Medicare and Medicaid services and fear of repercussions if one-year mortality falls below established values has led to a current state of excessive risk aversion for which organs are accepted for OHT. Furthermore, non-standardized utilization of extended criteria donors and donation after circulatory death, exacerbate the organ shortage. Data-driven systems can improve donor-recipient matching, better predict patient QoL post-OHT, and decrease needless organ waste through more uniform application of acceptance criteria. Thus, we propose a data-driven future for OHT and a move to patient-centric and holistic transplantation care processes.

Background: At the start of 2020, the kidney waiting list consisted of 2526 candidates with a calculated panel reactive antibody (CPRA) of 99.9% or greater, a cohort demonstrated in published research to have meaningfully lower than average access to transplantation even under the revised kidney allocation system (KAS). Methods: This was a retrospective analysis of US kidney registrations using data from the OPTN [Reference (https://optn.transplant.hrsa.gov/data/about‐data/)]. The period‐prevalent study cohort consisted of US kidney‐alone registrations who waited at least 1 day between April 1, 2016, when HLA DQ‐Alpha and DP‐Beta unacceptable antigen data became available in OPTN data collection, to December 31, 2019. Poisson rate regression was used to model deceased donor kidney transplant rates per active year waiting and using an offset term to account for differential at‐risk periods. Median time to transplant was estimated for each IRR group using the Kaplan–Meier method. Sensitivity analyses were included to address geographic variation in supply‐to‐demand ratios and differences in dialysis time or waiting time. Results: In this study, we found 1597 additional sensitized (CPRA 50–<99.9%) candidates with meaningfully lower than average access to transplant when simultaneously taking into account CPRA and other factors. In combination with CPRA, candidate blood type, Estimated Post‐Transplant Survival Score (EPTS), and presence of other antibody specificities beyond those in the current, 5‐locus CPRA were found to influence the likelihood of transplant. Conclusion: In total, this suggests approximately 4100 sensitized candidates are on the waiting list who represent a community of disadvantaged patients who may benefit from progressive therapies and interventions to facilitate incompatible transplantation. Though associated with higher risks, such interventions may nevertheless be more attractive than remaining on dialysis with the associated accumulation of mortality risk over time. [ABSTRACT FROM AUTHOR]

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Although rare, infection and vaccination can result in antibodies to human leukocyte antigens (HLA). We analyzed the effect of SARS-CoV-2 infection or vaccination on HLA antibodies in waitlisted renal transplant candidates. Specificities were collected and adjudicated if the calculated panel reactive antibodies (cPRA) changed after exposure. Of 409 patients, 285 (69.7 %) had an initial cPRA of 0 %, and 56 (13.7 %) had an initial cPRA > 80 %. The cPRA changed in 26 patients (6.4 %), 16 (3.9 %) increased, and 10 (2.4 %) decreased. Based on cPRA adjudication, cPRA differences generally resulted from a small number of specificities with subtle fluctuations around the borderline of the participating centers' cutoff for unacceptable antigen listing. All five COVID recovered patients with an increased cPRA were female (p = 0.02). In summary, exposure to this virus or vaccine does not increase HLA antibody specificities and their MFI in approximately 99 % of cases and 97 % of sensitized patients. These results have implications for virtual crossmatching at the time of organ offer after SARS-CoV-2 infection or vaccination, and these events of unclear clinical significance should not influence vaccination programs. [ABSTRACT FROM AUTHOR]

Background: Effects of kidney injury (KI) at the time of liver transplantation (LT) for acute liver failure (ALF) remain poorly described. We hypothesized that patients with ALF and KI who undergo LT have persistent post‐transplant KI, inferior survival, and increased rate of kidney transplantation (KT). Methods: The US Scientific Registry of Transplant Recipients database was queried for patients transplanted with status 1 listing for LT between 2002 and 2021. KI was defined as estimated glomerular filtration rate (eGFR) ≤ 30 mL/min/1.73 m2 or dialysis in the week prior to LT. Outcomes evaluated were post‐LT eGFR, listing for subsequent KT, and overall survival (OS) after LT. Results: A total of 2984 patients underwent LT for ALF with 1241 (41.6%) having KI. KI patients had lower eGFR at 6 months post‐LT (57.8 vs. 68.7, p <.001) that persisted out to 5 years (59.9 vs. 69.7, p <.001). KI patients were more likely to be listed for KT (4.3% vs. 1.9%, p <.001) and undergo listing sooner after LT (.8 vs. 3.7 years, p <.001). Patients without KI had higher adjusted post‐transplant OS compared to those with KI (HR.75, p <.001). Conclusion: KI in the setting of ALF portends a worse prognosis for both kidney recovery and OS. [ABSTRACT FROM AUTHOR]

Organ procurement organizations (OPOs) play a central role in the recovery, preservation, and distribution of deceased donor kidneys for transplantation in the United States. We conducted a national survey to gather information on OPO practices and perceived barriers to efficient organ placement in the face of the new circle‐based allocation and asked for suggestions to overcome them. Of the 57 OPOs, 44 responded (77%). The majority of OPOs (61%) reported barriers to obtaining a kidney biopsy, including lack of an available pathologist. Most OPOs (55%) indicated barriers to pumping owing to a lack of available staff and transportation. Respondents agreed or strongly agreed that the new allocation system has worsened transportation challenges (85%), increased provisional acceptances of kidneys (66%), increased communication challenges with transplant centers (68%), and worsened the efficiency of organ allocation (83%). OPO‐suggested solutions include making transplant centers more accountable for inefficient selection practices, developing reliable transportation options, and removing the requirement for national sharing. These findings underscore the need to examine closely the trade‐offs of the new allocation system with respect to costs, organ ischemia, and discard. These findings may help inform practice and policy for overcoming transportation barriers and improving the efficiency of organ placement. [ABSTRACT FROM AUTHOR]

Acute-on-chronic liver failure (ACLF) is a clinical syndrome characterized by intense systemic inflammatory response, multiple-organ failures, and high short-term mortality in patients with chronic liver disease. ACLF is dynamic and heterogeneous, and the prognosis is closely related to the clinical course. Currently, liver transplantation (LT) remains the only potential curative treatment that improves survival of ACLF patients. In this review, we summarize the dynamic clinical course of ACLF and the relationship between the clinical course and the post-LT prognosis, especially the factors affecting the mortality after LT in severe ACLF patients and explore the optimal choice of LT therapy for ACLF patients, both to benefit patients the most and to avoid futile therapy. ACLF is a dynamic disease with varying clinical phenotypes, and the global burden is high. Early identification of the clinical course is important to assess the prognosis and guide the treatment. The contradiction between shortage of liver donors and the large number of recipients makes it necessary for us to strictly screen out the recipients and identify patients who really need LT to save liver sources. [ABSTRACT FROM AUTHOR]

Purpose of review: Cardiac transplantation is a critical treatment for patients with advanced heart failure, offering the ability to markedly improve quality and quantity of life. Unfortunately, this treatment is limited by donor organ availability, despite efforts to increase organ supply and improve donor organ allocation and usage. The transplantation of non-human donor organs (xenotransplantation) offers to readily address many limitations of the current transplantation system; however, scattered attempts to establish this practice have been met with frustration. In this review, we discuss the limitations of the historical attempts and outline recent progress in the field of cardiac xenotransplantation. Recent findings: The advent of CRISPR-Cas9 genome editing techniques and emerging commercial and regulatory alignment has led to a flurry of new attempts to establish xenotransplantation as a viable treatment for those with end-stage heart failure. The first xenotransplantation of a genetically modified pig heart to a human recipient on January 7, 2022, highlighted the progress the science of xenotransplantation has made, as well as the need to outline next steps to further establish the practice. Summary: The development of a genetically modified porcine model has renewed hope that xenotransplantation might succeed where prior attempts failed, though many barriers remain. [ABSTRACT FROM AUTHOR]